Dental Students' Discomfort and Anxiety During the First and the Second Lockdown Due to COVID-19 Pandemic at the School of Dental Medicine, University of Zagreb.

OBJECTIVES: The aim of the study was to assess discomfort and anxiety of dental students caused by the COVID-19 pandemic crisis and to assess quality of the study during the crisis, as well as to compare subjective experiences and attitudes of preclinical and clinical students towards lectures and practicals during the first and the second lockdown at the School of Dental Medicine, University of Zagreb.
METHODS: This research was conducted using online questionnaires. The questionnaires were compiled by students for a presentation at the Brescia Colloquium 2020. The participants were integrated undergraduate and graduate dental students from the School of Dental Medicine, University of Zagreb. The questionnaires were completed by students during March 2020 and during February 2021 and were anonymous. For the statistical analysis of the data, the software package SPSS 20 (IBM Corp., Armonk, New York, USA) was used. Descriptive statistical analysis was used to determine the basic statistical parameters (frequencies, median, mod, minimum and maximum values). The significance of the differences among the tested groups was assessed by the Chi-Square or the Fisher's Exact Tests.
RESULTS: All dental students experienced some discomfort and were worried about the future competence. No gender differences were found (p>0.05). Preclinical students were less motivated than clinical students (p<0, 01) during first lockdown, while significant differences were found between preclinical and clinical students considering safety, competence and confidence to treat patients during second lockdown.
CONCLUSIONS: COVID-19 pandemic impacted the wellbeing of the students, their learning and teaching at the School of Dental Medicine, University of Zagreb. Students were more overwhelmed by the pandemic during the first lockdown than during second lockdown and have adapted well to the new forms of teaching. However, they are still uncertain about competency in the clinical environment and their future career.

Introduction

The aim of the study was to point out the effects of the COVID-19 pandemic on the quality of study and to compare subjective experiences of students of dental medicine during the first and the second lockdown (2020 and 2021, respectively) at the School of Dental Medicine, University of Zagreb.

In December 2019, the first cases of novel coronavirus disease (COVID-19), caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2) were reported in Wuhan, China (). The outbreak of the COVID-19 rapidly escalated causing the worldwide pandemic, which was declared as such on January 30th, 2020 by the World Health Organisation (WHO) (). The pandemic has impacted not only the health care system, thus causing millions of deaths and global health care crisis, but also the course of education at Universities around the world, which had to either postpone or cancel their activities and/or to switch to alternative teaching and learning methods (online classes) (, ). The changes in the delivery of the study programme, which were primarily introduced to stop the spread of COVID-19 and thus protect the students of dental medicine, subsequently had an impact on quality of education, as well as on students’ subjective experiences (). The presence of coronavirus within the oral cavity and its spread during clinical work in dental offices has put our profession amongst one of the riskiest professions and has closed clinical practice and education in dental medicine (). In the study of dental medicine, acquiring clinical skills is needed to carry out dental procedures, which is of utmost importance and heavily depends on practical exercises. In addition to lectures and seminars, the dental medicine study curriculum is composed of preclinical and clinical exercises.

Students of dental medicine were thus considerably affected by the change of teaching and learning methods and the way of work at the clinics. Having lost a significant amount of practical exercises, students’ clinical competencies were jeopardised. Furthermore, due to continuous droplet and aerosol-generating procedures, dental students working at the clinics are at higher risk of exposure to the COVID-19, thus appropriate precautionary measures must be taken to prevent and control the spread of the SARS-CoV-2 (, ).

On March 20th, 2020 Croatian government declared closing of all educational institutions, including the School of Dental Medicine, University of Zagreb. Only 12 days later, a complete lockdown was imposed, except for pharmacies and grocery stores (). In addition, on March 22nd, 2020 Zagreb, the capital of Croatia, was hit by a powerful earthquake with a magnitude of 5.5 according to Richter’s scale. Thus, during the first lockdown, the School of Dental Medicine was completely closed all indoor lectures, seminars and practicals. All teaching was delivered online until the end of the academic year 2019/2020.

During the second lockdown, which began on the 26th of November 2020, most schools in Croatia continued to carry out all teaching online due to the pandemic, as well as due to material damage from the earthquake. Nevertheless, the School of Dental Medicine managed to be renovated and managed to provide appropriate protection for all students and employees. Face shields, disposable protective gowns, surgical masks and gloves were provided. Additionally, the classrooms and other rooms were well ventilated and the number of persons in the room was minimized. Consequently, preclinical and clinical exercises were delivered in-person, while lectures and seminars remained online ().

The objectives of this research were to find out the impact of the COVID-19 pandemic crisis on the students of dental medicine during the first lockdown, and to compare the results of their current experience of studying in terms of their subjective attitudes towards: the COVID-19 situation and its impact on their education, their satisfaction with the current way of the study program being delivered, the amount of preclinical/clinical practice, their competence in using PPE during the preclinical/clinical exercises, overall safety in the preclinical/clinical environment, the possibility of compensating for the lost preclinical/clinical exercises, the prospects of employment.

Materials and methods:

Ethical consideration

The research, questionnaire and consent statement have been approved by the Ethics Committee of the School of Dental Medicine, University of Zagreb, protocol number 05-PA-30-XXIII-2021.

Study design and data collection

The research is based on three individual questionnaires that were carried out in May 2020 for Brescia Colloquium and of one additional questionnaire (AQ) which was carried out in February 2021. Three individual questionnaires were designed for third-year students (questionnaire TQ), fourth-year students (questionnaire FQ) and sixth-year students (questionnaire SQ). The results of the respective questionnaires were statistically analysed and compared to see the differences of studying experiences during the first and the second lockdown, and between the preclinical and clinical students and gender. The additional questionnaire (AQ) was composed of 12 questions and was a follow-up to the abovementioned group of questionnaires (TQ, FQ and SQ). The AQ, as well as the TQ, FQ and SQ, were delivered in a form of a Google Form application in February 2021. Dental students were approached with the help of social media for filling in the online questionnaire via link. Twelve questions in the questionnaires were related to students' opinions about studying during the COVID-19 pandemic. Individual opinions were assessed using a 4-point scale (1-Agree, 2-Neutral, 3-Disagree, 4-I don’t know). The last question was optional and collected only qualitative data. The questionnaires did not collect any personal data and were filled out voluntarily. The participants of the study gave their online consents to participate in the study by submitting an answer.
Content and Face validity
The study instrument was validated before being distributed to the study sample. To ensure content validity, the questionnaire was sent out to two academics from the School of Dental Medicine, University of Zagreb, for structured and unstructured feedback and it was later sent to three randomly chosen dental students from the School of Dental Medicine, University of Zagreb, for face validity.
 Participants

The participants were 120 dental students of the School of Dental Medicine, University of Zagreb from the first to the sixth year of the integrated study program. The response rate for AQ was 19%, for TQ 47%, FQ 42% and for SQ 40%.

Inclusion criteria
Undergraduate dental students from the School of Dental Medicine, University of Zagreb.
Exclusion criteria
Postgraduate dental students from the School of Dental Medicine, University of Zagreb.

Statistical methods

For the statistical analysis of the data, the software package SPSS 20 (IBM Corp., Armonk, New York, USA) was used. Descriptive statistical analysis was used to determine the basic statistical parameters (frequencies, median, mod, minimum and maximum values). The significance of the differences among the tested groups was assessed by the Chi-Square or the Fisher's Exact Tests.

Results

Results from the 2020 questionnaire (Questionnaire TQ and FQ)

The questionnaires, which included the 3rd and the 4th-year students, were answered by 79 dental students. No differences between genders were found (p>0.05). No differences existed between the preclinical and the clinical students (p>0.05), except for the motivation since clinical students were significantly more motivated (p<0, 01). The results confirmed that all students felt discomfort and anxiety towards the future of obtaining their academic knowledge, as well as their practical competencies, which were deprived of during the first lockdown (Table 1). A significant amount (65%) of the 3rd-year dental students did not feel competent to do future clinical work, with the knowledge they obtained through the course of the first lockdown (Figure 1). The results showed that only 40% of the 3rd-year students felt competent using the protective equipment necessary for the clinical work (Figure 2). During the first lockdown, 51% of the students from the 4th-year felt satisfied with the substitution of clinical exercises with online classes, considering the situation in the world (Figure 3).

Table 1

Attitudes of preclinical and the clinical students about discomfort, anxiety and other attitudes during the post-lockdown 2020, and significance of differences between preclinical and clinical students (X2 or Fisher's exact test).

	Preclinical	Clinical	X2 or Fisher’s exact	P value
Question 1	I am feeling anxious about this situation. * Preclinical/clinical
Don’t know	0	0	1.36	0.51 NS
Agree	15	12
Neutral	15	9
Disagree	13	15
Question 2	I find it hard to find the motivation to study and do the assigned work.
Don’t know	0	0	21.90	<0.001 **
Agree	33	11
Neutral	7	7
Disagree	3	18
Question 3	I think that this situation is having a huge impact on my clinical skills.
Don’t know	0	0	3.33	0.23 NS
Agree	27	26
Neutral	15	7
Disagree	1	3
Question 4	My current way of education is able to substitute clincal/preclinical exercises.
Don’t know	0	0	1.49	0,53 NS
Agree	3	1
Neutral	4	6
Disagree	36	29
Question 5	I have improved my theoretical knowledge more than I would if there was no Covid-19 pandemic.
Don’t know	0	0	7.80	0,018 NS
Agree	24	30
Neutral	14	3
Disagree	5	3

NS=not significant

*=<0.05

**=<0.01

Figure 1

I feel competent to do the clinical part of my dentistry studies next year (third-year students).

Figure 2

I feel competent using the protective equipment necessary for the clinical work (third-year students).

Figure 3

Considering the situation, I am satisfied with online classes as a substitution for clinical work (fourth-year students).

Statistical analysis between preclinical and clinical students (AQ Questionnaire) from the 2021 questionnaire
All students answered twelve questions. Their opinions were almost uniform, confirming discomfort and anxiety about their future acceptance of the knowledge and practical skills, as they were deprived of exercises during the closure due to the COVID-19 pandemic (Table 2).
The 12th question gathered additional comments and could be translated into qualitative data. Three answers were noted and all of them were satisfactory, e.g. ‘’Lectures are better online because they are recorded and I can rewatch them whenever I need, seminars and preclinical exercises definitely not because students are not well prepared (I would say it’s because of loss of motivation) and some professors are frustrated.’’

Table 2

Attitudes of dental students of preclinical and clinical years of study towards discomfort and anxiety during the lockdown in 2021 due to the COVID-19, and the significance of the differences between them (X2 or Fisher's exact test).

	Preclinical students	Clinical students	X2 or Fisher’s exact	P value
Question 1	Compared to the first lock-down at the beginning of the year, I feel less anxious about the COVID-19 situation.
Don’t know	1	0	1.14	0.63 NS
Agree	81	19
Neutral	14	5
Disagree
Question 2	I think that I won't be able to compensate missed clinical work.
Don’t know	11	1	1.96	0.58 NS
Agree	32	9
Neutral	26	9
Disagree	27	5
Question 3	The School of Dental Medicine, University of Zagreb has organized compensation for the lost preclinical/clinical exercises during the first lock-down.
Don’t know	0	0	11.28	0.003 **
Agree	26	13
Neutral	47	11
Disagree	23	0
Question 4	Because of the lost preclinical/clinical exercises during the first lock-down I feel less confident working on patients this year.
Don’t know	28	0	13.96	0.002**
Agree	32	15
Neutral	18	6
Disagree	18	3
Question 5	Due to the current COVID-19 situation I have an impression that I am treating less patients than before.
Don’t know	17	1	9.75	0.018**
Agree	21	11
Neutral	5	6
Disagree	7	5
Question 6	I believe that the current way of preclinical/clinical exercises and online learning is having a positive effect on my education.
Don’t know	4	0	0.65	0.98 NS
Agree	35	10
Neutral	21	5
Disagree	36	9
Question 7	I adapted well to the current way of how educational programme (lectures, seminars, preclinical/clinical exercises...) is being delivered.
Don’t know	0	0	0.59	0.74 NS
Agree	73	17
Neutral	12	4
Disagree	11	3
Question 8	I find online lectures/seminars better than those delivered in person.
Don’t know	0	0	2.47	0.24 NS
Agree	42	15
Neutral	23	4
Disagree	31	5
Question 9	I feel competent using the PPE (personal protective equipment) during the preclinical/clinical exercises.
Don’t know	17	0	6.46	0.03*
Agree	59	17
Neutral	18	7
Disagree	2	0
Question 10	I feel safe and well protected in the environment of the preclinical/clinical exercises (the rooms are well ventilated; the number of people in the room is minimized...).
Don’t know	10	0	3.49	0.29 NS
Agree	71	19
Neutral	9	4
Disagree	6	1
Question 11	The current pandemic crisis will have an impact on my future career as a dentist.
Don’t know	10	3	3.64	0.31 NS
Agree	52	10
Neutral	13	7
Disagree	21	4

NS=not significant

*=<0.05

**=<0.01

‘’Online learning should exist also after covid.’’

‘’I like the concept of online lectures and I think that we should keep ONLINE lectures and (pre)clinical exercises at faculty even when some of the pandemic measures are cancelled. lectures and handouts being uploaded on merlin platforms has been a HUGE help and that’s something a lot of subjects didn’t do before.’’
3.2.2. Statistical analysis based on gender (AQ Questionnaire)

There were no differences between female and male students. Both genders confirmed discomfort and anxiety about the future acceptance of knowledge and practical skills and competences because of closure due to the COVID-19 pandemic (Table 3).

Table 3

Attitudes of students about discomfort and anxiety during the lockdown 2021 and significance of the diferences between gender.

	Male	Female	X2 or Fisher’s exact	P value
Question 1	Compared to the first lockdown at the beginning of the year, I feel less anxious about the COVID-19 situation.
Don’t know	0	1	1.15	0.58 NS
Agree	15	85
Neutral	4	15
Disagree
Question 2	I think that I won't be able to compensate missed clinical work.
Don’t know	1	11	2.54	0.48 NS
Agree	7	34
Neutral	8	27
Disagree	3	29
Question 3	The School of Dental Medicine. University of Zagreb has organised compensation for the lost preclinical/clinical exercises during the first lockdown.
Don’t know	0	0	0.95	0.62 NS
Agree	8	31
Neutral	8	50
Disagree	3	20
Question 4	Because of the lost preclinical/clinical exercises during the first lockdown I feel less confident working on patients this year.
Don’t know	6	22	0.92	0.81 NS
Agree	7	40
Neutral	3	21
Disagree	3	18
Question 5	Due to the current COVID-19 situation I have an impression that I am treating less patients than before. (Only for students working at the clinics)
Don’t know	4	14	1.54	0.67 NS
Agree	4	28
Neutral	3	8
Disagree	2	10
Question 6	I believe that the current way of preclinical/clinical exercises and online learning is having a positive effect on my education.
Don’t know	1	3	2.18	0.49 NS
Agree	6	39
Neutral	6	20
Disagree	6	39
Question 7	I adapted well to the current way of how educational programme (lectures, seminars, preclinical/clinical exercises...) is being delivered.
Don’t know			1.69	0.44 NS
Agree	14	76
Neutral	4	12
Disagree	1	13
Question 8	I find online lectures/seminars better than those delivered in person.
Don’t know	0	0	3.47	0.17 NS
Agree	9	48
Neutral	7	20
Disagree	3	33
Question 9	I feel competent using the PPE (personal protective equipment) during the preclinical/clinical exercises.
Don’t know	3	14	0.41	1.00 NS
Agree	12	64
Neutral	4	21
Disagree	0	2
Question 10	I feel safe and well protected in the environment of the preclinical/clinical exercises (the rooms are well ventilated, the number of people in the room is minimized....).
Don’t know	1	9	0.31	1.00 NS
Agree	15	75
Neutral	2	11
Disagree	1	6
Question 11	The current pandemic crisis will have an impact on my future career as a dentist.
Don’t know	1	12	4.98	0.15 NS
Agree	12	50
Neutral	5	15
Disagree	1	24

NS=not significant

*=<0.05

**=<0.01

Influence of the pandemic crisis on the future career perspectives (AQ and SQ Questionnaire)

There was a significant difference between the opinions of the 6th-year students about the influence of the pandemic crisis on their future careers as dentists. In 2020, most students were neutral and disagreed with the mentioned statement, while in 2021 they mostly agreed that COVID-19 will have an impact on their future career (p<0,01) (Figure 4).

Figure 4

The current pandemic crisis will have an impact on my future career as a dentist (sixth-year students).

Discussion

The spread of the COVID-19 pandemic has immediate effect on dental education, forcing universities to cancel all of their in-person activities and to switch to a virtual environment, thus forcing dental students to adapt to new forms of learning and teaching ((–, )). The delivery of the curricula on the online platform greatly relies on the technical capacity of dental school, students’ access to the internet and a possibility to use computers at home, as well as it relies on digital literacy of the University staff ((, –)). There is not much evidence showing a plausible effect on higher education, however one study does show that there could be some positive effects of COVID-19 on the students’ performance (()). According to conclusions of systemic review of Regmi K et al (2020), distance education could enhance learning and performance because of its accessibility and flexibility (()). Several studies have shown that students find e-learning gratifying ((,)). Moreover, it was also reported that both students and professors appreciated e-learning in terms of teacher-student interaction, however, remote teaching cannot replace clinical training (()). When analyzing the first and the second lockdown (2020 and 2021), 51% of the 4th-year dental students were satisfied with the online forms of teaching (Figure 3). More interestingly, during the first lockdown, majority of the participants agreed that they improved their theoretical knowledge more than they would have done if there had not been the COVID-19 pandemic (Table 1). However, during the second lockdown, the downgrade of the students’ opinion was noted (Table 2, Table 3). The downgrade of the experience could be explained by the lack of digital literacy of some of the faculty staff and/or students’ fatigue of the online forms of teaching and learning ((,)). The Council of European Dentists (CED) does mention in their policy paper that the European dental education institutions should invest in a suitable infrastructure to ensure the appropriate quality of online education, whilst exploiting the power of technology for learning and teaching. Moreover, students should also be supported (financially, instructive, etc.) to develop better skills in digital health, communication, resilience, advocacy, public health and well-being (()).
One should note that not all students might have access to the internet or laptops to work from home (()). Despite the online forms of teaching being acceptable and appropriate to deliver seminars, lectures or non-clinical programmes, dental students worldwide have been deprived of the critical hands-on practice, which is one of the most crucial parts of their education ((, )). Comparing the results from the first lockdown, dental students from Zagreb, are still uncertain whether they will be able to compensate for the missed clinical work (Tables 1-3).
According to the paper published by Hattar et al (2021), dental students from the University of Jordan, sensed that they had missed important learning experiences, especially when it comes to the clinical practice and also have felt less involved in following up with distant learning (()). The School of Dental Medicine, University of Zagreb has organized additional preclinical/clinical exercises during the first lockdown as compensation for student terms lost during the lockdown, however only for certain subjects. Furthermore, the University has opened a possibility to volunteer at the University’s clinics, during the summer and winter break, as well as during the exam period. The subjects that consist of practical work require interactions in both preclinical and clinical settings; therefore it is not surprising that dental students from Zagreb are still uncertain about their clinical competency(Table 3).

The School of Dental Medicine in Zagreb had to adapt their clinical settings to ensure the safety of staff and students, and most importantly safeguard the continuity of clinical education. During the first lockdown, 40% of the students felt competent using the PPE, whereas, after the second lockdown, more students have reported they felt competent using the PPE (Figure 2, Table 2, Table 3). Such findings are logical as the students were instructed on how to properly use the PPE. The University has organized the clinical work at the University but has reduced the number of students per group; the groups were cut in half. Consequently, the amount of clinical practice was reduced for an individual student as well. The majority of students reported they felt safe and well protected in the environment of the preclinical/clinical exercises (Table 2, Table 3). Despite the efforts of School of Dental Medicine to deliver clinical practice to their students, students still believed that, due to the COVID-19, they were treating fewer patients than before and have shown the concern that the COVID-19 would have an impact on their future career as dentists (Table 2, Table 3, Figure 4). Since patient care was at a halt, academic institutions were concerned about graduating dental students. There have been uncertainties about their clinical competences and their abilities to meet clinical requirements made by the accreditation bodies, as well as the preparedness to provide dental care in the post-COVID-19 era (()). The Dental Schools Council (DCS), which is the representative body for dental schools across the UK and Ireland, have mentioned in their paper that the students in all year cohorts have faced the reduction in clinical experience since March 2020 and may have to acquire the clinical skills in the slower, reduced rate for some time in the future. They are pointing out that this is of big relevance for those who are entering their final years of study and that the increase of the additional clinical exposure is of great importance. To facilitate the opportunity for the additional clinical work they have created the measures that include extending or altering the sessions within the normal working day for dental students and dental teaching staff. According to DSC, dentistry degree programmes in the UK could be extended if the students did not have an opportunity to gain sufficient practical experience to meet the learning outcomes of the curricular programme ((,)). Moreover, the Council of European Dentists’ (CED) position is that there is a need to find the balance between in-person and online teaching. They have also called dental institutions to define a set of minimum requirements to be fulfilled by the students so that adequate European dental education is ensured and that the teaching settings should be in line with the minimal clinical requirements expressed in the Professional Qualifications Directive (PQD) (()).

Apart from the missed in-person teaching and the lack of clinical experience, the COVID-19 pandemic created a level of uncertainty and anxiety about future happenings, thus causing an exceeded level of stress among students leading to unfavorable effects on the learning and psychological health of students ((,,)). Fear and discomfort in 2020, as well as in 2021, were statistically not significantly different between observed groups, but existed in both years (Table 1, Table 2, Table 3). Even before the outbreak of the COVID-19, discomfort and stress were common amongst students entering the student life due to expectations, pressure to study and pass exams ((-)). During the first lockdown, students felt even more anxious than they did during the second lockdown, which could be explained by adaptations to some new forms of teaching, and decreased levels of stress and fear for both their own and for family’s health since more information on COVID-19 was available (Table 1, Table 2, Table 3), and vaccination has just begun. Dental Schools in the UK, as reported by the DCS, are aware that dental students, who undertake an already demanding course, have faced challenges and stressors during the pandemic. Therefore, they are investing a lot of effort to support student wellbeing and are striving to provide students with information on any changes to their courses (()). At the School of Dental Medicine, University of Zagreb, there are no additional programmes available that would support mental health of their dental students; however more assessment is needed to measure the wellbeing of dental students.

Conclusions

The present study showed that the students were uncomfortable by the COVID-19 pandemic crisis during the first lockdown and the second lockdown (2020 and 2021, respectively). The students have adapted well to the new forms of hybrid teaching, however, they are aware that dental education needs practice and clinical exposure, which is something that cannot be delivered online. Despite the striving of the School of Dental Medicine to compensate for the missed clinical exercises, students still feel uncertain about their clinical competence. There was no significant difference between genders, while clinical students were more motivated during the first lockdown. During the second lockdown, preclinical students felt safer but less confident to treat patients.